10 This is My covenant, which ye shall keep, between Me and you and thy seed after thee: every male among you shall be circumcised. 11 And ye shall be circumcised in the flesh of your foreskin; and it shall be a token of a covenant betwixt Me and you. 12 And he that is eight days old shall be circumcised among you, every male throughout your generations, he that is born in the house, or bought with money of any foreigner, that is not of thy seed. 13 He that is born in thy house, and he that is bought with thy money, must needs be circumcised; and My covenant shall be in your flesh for an everlasting covenant. 14 And the uncircumcised male who is not circumcised in the flesh of his foreskin, that soul shall be cut off from his people; he hath broken My covenant.

Also, Leviticus 12:3 provides: "And in the eighth day the flesh of his foreskin shall be circumcised."

According to the Hebrew Bible, it was "a reproach" for an Israelite to be uncircumcised (Joshua 5:9.) The term arelim ("uncircumcised" [plural]) is used opprobriously, denoting the Philistines and other non-Israelites (I Samuel 14:6, 31:4; II Samuel 1:20) and used in conjunction with tameh (unpure) for heathen (Isaiah 52:1). The word arel ("uncircumcised" [singular]) is also employed for "impermeable" (Leviticus 26:41, "their uncircumcised hearts"; compare Jeremiah 9:25; Ezekiel 44:7, 9); it is also applied to the first three years' fruit of a tree, which is forbidden (Leviticus 19:23).

However, the Israelites born in the wilderness after the Exodus from Egypt were not circumcised. Joshua 5:2–9, explains, "all the people that came out" of Egypt were circumcised, but those "born in the wilderness" were not. Therefore, Joshua, before the celebration of the Passover, had them circumcised at Gilgal specifically before they entered Canaan. Abraham, too, was circumcised when he moved into Canaan.

The prophetic tradition emphasizes that God expects people to be good as well as pious, and that non-Jews will be judged based on their ethical behavior, see Noahide Law. Thus, Jeremiah 9:25–26 says that circumcised and uncircumcised will be punished alike by the Lord; for "all the nations are uncircumcised, and all the house of Israel are uncircumcised in heart."

As found in Genesis 17:1–14, brit milah is considered to be so important that should the eighth day fall on the Sabbath, actions that would normally be forbidden because of the sanctity of the day are permitted in order to fulfill the requirement to circumcise.[1] The Talmud, when discussing the importance of Milah, compares it to being equal to all other mitzvot (commandments) based on the gematria for brit of 612 (Tractate Nedarim 32a).

Covenants in ancient times were sometimes sealed by severing an animal, with the implication that the party who breaks the covenant will suffer a similar fate. In Hebrew, the verb meaning "to seal a covenant" translates literally as "to cut". It is presumed by Jewish scholars that the removal of the foreskin symbolically represents such a sealing of the covenant.[2]

A mohel is a Jew trained in the practice of brit milah, the "covenant of circumcision." According to traditional Jewish law, in the absence of a grown free Jewish male expert, anyone who has the required skills is also authorized to perform the circumcision, provided that they are Jewish.[9] However, most streams of non-Orthodox Judaism allow female mohels, called mohalot (Hebrew: מוֹהֲלוֹת‎, plural of מוֹהֶלֶתmohelet, feminine of mohel), without restriction. In 1984, Deborah Cohen became the first certified Reform mohelet; she was certified by the Berit Mila program of Reform Judaism.[10]

It is customary for the brit to be held in a synagogue, but it can also be held at home or any other suitable location. The brit is performed on the eighth day from the baby's birth, taking into consideration that according to the Jewish calendar, the day begins at the sunset of the day before. If the baby is born on Sunday before sunset, the Brit will be held the following Sunday. However, if the baby is born on Sunday night after sunset, the Brit is on the following Monday. The brit takes place on the eighth day following birth even if that day is Shabbat or a holiday. A brit is traditionally performed in the morning, but it may be performed any time during daylight hours.[11]

The Talmud explicitly instructs that a boy must not be circumcised if he had two brothers who died due to complications arising from their circumcisions,[12] and Maimonides says that this excluded paternal half-brothers. This may be due to a concern about hemophilia.[12]

In recent years, the circumcision of adult Jews who were not circumcised as infants has become more common than previously thought.[14] In such cases, the brit milah will be done at the earliest date that can be arranged. The actual circumcision will be private, and other elements of the ceremony (e.g., the celebratory meal) may be modified to accommodate the desires of the one being circumcised.

Most prominent acharonim rule that the mitzvah of brit milah lies in the pain it causes, and anesthetic, sedation, or ointment should generally not be used.[15] However, it is traditionally common to feed the infant a drop of wine or other sweet liquid to soothe him.[16][17]

The title of kvater among Ashkenazi Jews is for the person who carries the baby from the mother to the father, who in turn carries him to the mohel. This honor is usually given to a couple without children, as a merit or segula (efficacious remedy) that they should have children of their own. The origin of the term is Middle High Germangevater(e) ("godfather").[21]

After the ceremony, a celebratory meal takes place. At the birkat hamazon, additional introductory lines, known as Nodeh Leshimcha, are added. These lines praise God and request the permission of God, the Torah, Kohanim and distinguished people present to proceed with the grace. When the four main blessings are concluded, special ha-Rachaman prayers are recited. They request various blessings by God that include:

At the neonatal stage, the inner preputial epithelium is still linked with the surface of the glans.[22]
The mitzvah is executed only when this epithelium is either removed, or permanently peeled back to uncover the glans.[23]
On medical circumcisions performed by surgeons, the epithelium is removed along with the foreskin,[24] to prevent post operative penile adhesion and its complications.[25]
However, on ritual circumcisions performed by a mohel, the epithelium is most commonly peeled off only after the foreskin has been amputated. This procedure is called priah (Hebrew: פריעה‎), which means: 'uncovering'. The main goal of "priah" (also known as "bris periah"), is to remove as much of the inner layer of the foreskin as possible and prevent the movement of the shaft skin, what creates the look and function of what is known as a "low and tight" circumcision.[26]

According to Rabbinic interpretation of traditional Jewish sources,[27] the 'priah' has been performed as part of the Jewish circumcision since the Israelites first inhabited the Land of Israel.[28]
However, the Oxford Dictionary of the Jewish Religion, states that many Hellenistic Jews attempted to restore their foreskins, and that similar action was taken during the Hadrianic persecution, a period in which a prohibition against circumcision was issued. Thus, the writers of the dictionary hypothesize that the more severe method practiced today was probably begun in order to prevent the possibility of restoring the foreskin after circumcision, and therefore the rabbis added the requirement of cutting the foreskin in periah.[29] The frenulum may also be cut away at the same time, in a procedure called frenectomy.[30]
According to Shaye J. D. Cohen, in Why Aren't Jewish Women Circumcised?: Gender and Covenant in Judaism, pg 25, the Torah only commands circumcision (milah.)[31] David Gollaher has written that the rabbis added the procedure of priah to discourage men from trying to restore their foreskins: ‘Once established, priah was deemed essential to circumcision; if the mohel failed to cut away enough tissue, the operation was deemed insufficient to comply with God's covenant’ and ‘Depending on the strictness of individual rabbis, boys (or men thought to have been inadequately cut) were subjected to additional operations.’[32]

The guard (top center) is slid over the foreskin as close to the glans as possible to allow for maximum removal of the former without any injury to the latter. The scalpel is used to detach the foreskin, and the underlying blue bag is a sterilization pouch for the metal tools. The tube (center left) was used for metzitzah
In addition to milah (the actual circumcision) and p'riah, mentioned above, the Talmud (Mishnah Shabbat 19:2) mentions a third step, metzitzah, translated as suction, as one of the steps involved in the circumcision rite. The Talmud writes that a "Mohel (Circumciser) who does not suck creates a danger, and should be dismissed from practice".[33][34]Rashi on that Talmudic passage explains that this step is in order to draw some blood from deep inside the wound to prevent danger to the baby.[35]
There are other modern antiseptic and antibiotic techniques—all used as part of the brit milah today—which many say accomplish the intended purpose of metzitzah, however, since metzitzah is one of the four steps to fulfill Mitzvah, it continues to be practiced by a minority of Orthodox and Hassidic Jews.[36]

The ancient method of performing metzitzah—metzitzah b'peh, or oral suction[37][38]—has become controversial. The process has the mohel place his mouth directly on the circumcision wound to draw blood away from the cut. The majority of Jewish circumcision ceremonies do not use metzitzah b'peh,[39] but some Haredi Jews use it.[40][41][42] It has been documented that the practice poses a serious risk of spreading herpes to the infant.[43][44][45][46] Proponents maintain that there is no conclusive evidence that links herpes to Metzitza,[47] and that attempts to limit this practice infringe on religious freedom.[48][49][50]

The practice has become a controversy in both secular and Jewish medical ethics. The ritual of metzitzah is found in Mishnah Shabbat 19:2, which lists it as one of the four steps involved in the circumcision rite. Rabbi Moses Sofer (1762–1839) observed that the Talmud states that the rationale for this part of the ritual was hygienic — i.e., to protect the health of the child. The Chasam Sofer issued a leniency (Heter) that some consider to have been conditional to perform metzitzah with a sponge to be used instead of oral suction in a letter to his student, Rabbi Lazar Horowitz of Vienna. This letter was never published among Rabbi Sofer's responsa but rather in the secular journal Kochvei Yitzchok.[51] along with letters from Dr. Wertheimer, the chief doctor of the Viennese General Hospital. It relates the story that a mohel (who was suspected of transmitting herpes via metzizah to infants) was checked several times and never found to have signs of the disease and that a ban was requested because of the "possibility of future infections".[52]Moshe Schick (1807–1879), a student of Moses Sofer, states in his book of Responsa, She’eilos u’teshuvos Maharam Schick (Orach Chaim 152,) that Moses Sofer gave the ruling in that specific instance only because the mohel refused to step down and had secular Government connections that prevented his removal in favor of another mohel and the Heter may not be applied elsewhere. He also states (Yoreh Deah 244) that the practice is possibly a Sinaitic tradition, i.e., Halacha l'Moshe m'Sinai. Other sources contradict this claim, with copies of Moses Sofer's responsa making no mention of the legal case or of his ruling applying in only one situation. Rather, that responsa makes quite clear that "metzizah" was a health measure and should never be employed where there is a health risk to the infant.[53]

Chaim Hezekiah Medini, after corresponding with the greatest Jewish sages of the generation, concluded the practice to be Halacha l'Moshe m'Sinai and elaborates on what prompted Moses Sofer to give the above ruling.[54] He tells the story that a student of Moses Sofer, Lazar Horowitz, Chief Rabbi of Vienna at the time and author of the responsa Yad Elazer, needed the ruling because of a governmental attempt to ban circumcision completely if it included metztitzah b'peh. He therefore asked Sofer to give him permission to do brit milah without metzitzah b’peh. When he presented the defense in secular court, his testimony was erroneously recorded to mean that Sofer stated it as a general ruling.[55] The Rabbinical Council of America, (RCA) which claims to be the largest American organization of Orthodox rabbis, published an article by mohel Dr Yehudi Pesach Shields in its summer 1972 issue of Tradition magazine, calling for the abandonment of Metzitzah b'peh.[56] Since then the RCA has issued an opinion that advocates methods that do not involve contact between the mohel's mouth and the open wound, such as the use of a sterile syringe, thereby eliminating the risk of infection.[40] According to the Chief Rabbinate of Israel[57] and the Edah HaChareidis[58]metzitzah b'peh should still be performed.

The practice of metzitzah b'peh was alleged to pose a serious risk in the transfer of herpes from mohelim to eight Israeli infants, one of whom suffered brain damage.[43][59] When three New York City infants contracted herpes after metzizah b'peh by one mohel and one of them died, New York authorities took out a restraining order against the mohel requiring use of a sterile glass tube, or pipette.[42][60] The mohel's attorney argued that the New York Department of Health had not supplied conclusive medical evidence linking his client with the disease.[60][61] In September 2005, the city withdrew the restraining order and turned the matter over to a rabbinical court.[62] Dr. Thomas Frieden, the Health Commissioner of New York City, wrote, "There exists no reasonable doubt that ‘metzitzah b'peh’ can and has caused neonatal herpes infection....The Health Department recommends that infants being circumcised not undergo metzitzah b'peh."[63] In May 2006, the Department of Health for New York State issued a protocol for the performance of metzitzah b'peh.[64] Dr. Antonia C. Novello, Commissioner of Health for New York State, together with a board of rabbis and doctors, worked, she said, to "allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health."[65] Later in New York City in 2012 a 2-week-old baby died of herpes because of metzitzah b'peh.[66]

In three medical papers done in Israel, Canada, and the USA, oral suction following circumcision was suggested as a cause in 11 cases of neonatal herpes.[43][67][68] Researchers noted that prior to 1997, neonatal herpes reports in Israel were rare, and that the late incidences were correlated with the mothers carrying the virus themselves.[43] Rabbi Doctor Mordechai Halperin implicates the "better hygiene and living conditions that prevail among the younger generation", which lowered to 60% the rate of young Israeli Chareidi mothers who carry the virus. He explains that an "absence of antibodies in the mothers’ blood means that their newborn sons received no such antibodies through the placenta, and therefore are vulnerable to infection by HSV-1."[69]

Because of the risk of infection, some rabbinical authorities have ruled that the traditional practice of direct contact should be replaced by using a sterile tube between the wound and the mohel's mouth, so there is no direct oral contact. The Rabbinical Council of America, the largest group of Modern Orthodox rabbis, endorses this method.[70] The RCA paper states: "Rabbi Schachter even reports that Rav Yosef Dov Soloveitchik reports that his father, Rav Moshe Soloveitchik, would not permit a mohel to perform metzitza be’peh with direct oral contact, and that his grandfather, Rav Chaim Soloveitchik, instructed mohelim in Brisk not to do metzitza be’peh with direct oral contact. However, although Rav Yosef Dov Soloveitchik also generally prohibited metzitza be’peh with direct oral contact, he did not ban it by those who insisted upon it,...". The sefer Mitzvas Hametzitzah[71] by Rabbi Sinai Schiffer of Baden, Germany, states that he is in possession of letters from 36 major Russian (Lithuanian) rabbis that categorically prohibit Metzitzah with a sponge and require it to be done orally. Among them is Rabbi Chaim Halevi Soloveitchik of Brisk.

In September 2012, the New York Department of Health unanimously ruled that the practice of metztizah b'peh should require informed consent from the parent or guardian of the child undergoing the ritual.[72] Prior to the ruling, several hundred rabbis, including Rabbi David Neiderman, the executive director of the United Jewish Organization of Williamsburg, signed a declaration stating that they would not inform parents of the potential dangers that came with metzitzah b'peh, even if informed consent became law.[73]

In a motion for preliminary injunction with intent to sue, filed against New York City Department of Health & Mental Hygiene, affidavits by Awi Federgruen,[74][75] Brenda Breuer,[76][77] and Daniel S. Berman,[78][79] argued that the study on which the department passed its conclusions is flawed.[80][81][82][83]

The “informed consent” regulation was challenged in court. In January 2013 the U.S. District court ruled that the law did not specifically target religion and therefore must not pass strict scrutiny.

On August 15, 2014 the Second Circuit Court of Appeals reversed the decision by the lower court, and ruled that the regulation does have to be reviewed under strict scrutiny to determine whether it infringes on Orthodox Jews' freedom of religion.[85]

On September 9, 2015 after coming to an agreement with the community The New York City Board of Health voted to repeal the informed consent regulation.[86]

A brit milah is more than circumcision, it is a sacred ritual in Judaism, as distinguished from its non-ritual requirement in Islam. One ramification is that the brit is not considered complete unless a drop of blood is actually drawn. The standard medical methods of circumcision through constriction do not meet the requirements of the halakhah for brit milah, because they cause hemostasis, i.e., they stop the flow of blood. Moreover, circumcision alone, in the absence of the brit milah ceremony, does not fulfill the requirements of the mitzvah. Therefore, in cases where a Jew who was circumcised outside of a brit milah, an already-circumcised convert, or an aposthetic (born without a foreskin) individual, the mohel draws a symbolic drop of blood (Hebrew: הטפת דם‎, hatafat-dam) from the penis at the point where the foreskin would have been or was attached.[87]

A Milah L'shem giur is a "Circumcision for the purpose of conversion". In Orthodox Judaism, this procedure is usually done by adoptive parents for adopted boys who are being converted as part of the adoption or by families with young children converting together. It is also required for adult converts who were not previously circumcised, e.g. those born in countries where circumcision at birth is not common. The conversion of a minor is valid in both Orthodox and Conservative Judaism until a child reaches the age of majority (13 for a boy, 12 for a girl); at that time the child has the option of renouncing his conversion and Judaism, and the conversion will then be considered retroactively invalid. He must be informed of his right to renounce his conversion if he wishes. If he does not make such a statement, it is accepted that the boy is halakhically Jewish. Orthodox rabbis will generally not convert a non-Jewish child raised by a mother who has not converted to Judaism.[88]

The laws of conversion and conversion-related circumcision in Orthodox Judaism have numerous complications, and authorities recommend that a rabbi be consulted well in advance.

In Conservative Judaism, the Milah l'Shem giur procedure is also performed for a boy whose mother has not converted, but with the intention that the child be raised Jewish. This conversion of a child to Judaism without the conversion of the mother is allowed by Conservative interpretations of halakha. Conservative Rabbis will authorize it only under the condition that the child be raised as a Jew in a single-faith household. Should the mother convert, and if the boy has not yet reached his third birthday, the child may be immersed in the mikveh with the mother, after the mother has already immersed, to become Jewish. If the mother does not convert, the child may be immersed in a mikveh, or body of natural waters, to complete the child's conversion to Judaism. This can be done before the child is even one year old. If the child did not immerse in the mikveh, or the boy was too old, then the child may choose of their own accord to become Jewish at age 13 as a Bar Mitzvah, and complete the conversion then.[89]

The ceremony, when performed l'Shem giur, does not have to be performed on a particular day, and does not override Shabbat and Jewish Holidays.[90][91]

In Orthodox Judaism, there is a split of authorities on whether the child receives a Hebrew name at the Brit ceremony or upon immersion in the Mikvah. According to Zichron Brit LeRishonim, naming occurs at the Brit with a different formula than the standard Brit Milah. The more common practice among Ashkenazic Jews follows Rabbi Moshe Feinstein, with naming occurring at immersion.

Where the procedure was performed but not followed by immersion or other requirements of the conversion procedure (e.g., in Conservative Judaism, where the mother has not converted), if the boy chooses to complete the conversion at Bar Mitzvah, a Milah l'shem giur performed when the boy was an infant removes the obligation to undergo either a full brit milah or hatafat dam brit.

Nowadays it is generally assumed that Judaism adopted the practice of circumcision from neighboring cultures.

In Of the Special Laws, Book 1, the Jewish philosopher Philo (20 BCE – CE 50) gives six reasons for the practice of circumcision.[92] He attributes four of the reasons to "men of divine spirit and wisdom." These include the idea that circumcision:

protects against disease,

secures cleanliness "in a way that is suited to the people consecrated to God,"

causes the circumcised portion of the penis to resemble a heart, thereby representing a physical connection between the "breath contained within the heart [that] is generative of thoughts, and the generative organ itself [that] is productive of living beings," and

promotes prolificness by removing impediments to the flow of semen.

To these, Philo added two of his own reasons, including the idea that circumcision

"signified figuratively the excision of all superfluous and excessive pleasure," and

"is a symbol of a man's knowing himself."

Rabbi Saadia Gaon considers something to be "complete," if it lacks nothing, but also has nothing that is unneeded. He regards the foreskin an unneeded organ that God created in man, and so by amputating it, the man is completed.[93]

Maimonides (Moses ben Maimon "Rambam", CE 1135–1204), who apart from being a great Torah scholar was also a physician and philosopher, argued that circumcision serves as a common bodily sign to members of the same faith. He also asserted that the main purpose of the act is to repress sexual pleasure, with the strongest reason being that it is difficult for a woman to separate from an uncircumcised man with whom she has had sex.[94]

To complete the form of man, by removing what he claims to be a redundant organ;

To mark the chosen people, so that their bodies will be different as their souls are. The organ chosen for the mark is the one responsible for the sustenance of the species.

The completion effected by circumcision is not congenital, but left to the man. This implies that as he completes the form of his body, so can he complete the form of his soul.

Talmud professor Daniel Boyarin offered two explanations for circumcision. One is that it is a literal inscription on the Jewish body of the name of God in the form of the letter "yud" (from "yesod"). The second is that the act of bleeding represents a feminization of Jewish men, significant in the sense that the covenant represents a marriage between Jews and (a symbolically male) God.[96]

The Reform societies established in Frankfurt and Berlin regarded circumcision as barbaric and wished to abolish it. However, while prominent rabbis such as Abraham Geiger believed the ritual to be barbaric and outdated, they refrained from instituting any change in this matter. In 1843, when a father in Frankfurt refused to circumcise his son, rabbis of all shades in Germany stated it was mandated by Jewish law; even Samuel Holdheim affirmed this.[97] By 1871, Reform rabbinic leadership in Germany reasserted "the supreme importance of circumcision in Judaism", while affirming the traditional viewpoint that non-circumcised are Jews nonetheless. Although the issue of circumcision of converts continues to be debated, the necessity of Brit Milah for Jewish infant boys has been stressed in every subsequent Reform rabbis manual or guide.[98] Since 1984 Reform Judaism has trained and certified over 300 of their own practicing mohalim in this ritual.[99][100]

The ceremony of Brit shalom is not officially approved of by the Reform or Reconstructionist rabbinical organizations, who make the recommendation that male infants should be circumcised, though the issue of converts remains controversial[111][112] and circumcision of converts is not mandatory in either movement.[113]

The connection of the Reform movement to an anti-circumcision, pro-symbolic stance is a historical one.[114] From the early days of the movement in Germany and Eastern Europe,[114][115] some classical Reformers hoped to replace ritual circumcision "with a symbolic act, as has been done for other bloody practices, such as the sacrifices".[116] In the US, an official Reform resolution in 1893 announced converts are no longer mandated to undergo the ritual,[117] and this ambivalence towards the practice has carried over to classical-minded Reform Jews today. In Elyse Wechterman's essay A Plea for Inclusion, she argues that, even in the absence of circumcision, committed Jews should never be turned away, especially by a movement "where no other ritual observance is mandated". She goes on to advocate an alternate covenant ceremony, brit atifah, for both boys and girls as a welcoming ritual into Judaism.[118] With a continuing negativity towards circumcision still present within a minority of modern-day Reform, Judaic scholar Jon Levenson has warned that if they "continue to judge brit milah to be not only medically unnecessary but also brutalizing and mutilating ... the abhorrence of it expressed by some early Reform leaders will return with a vengeance", proclaiming that circumcision will be "the latest front in the battle over the Jewish future in America".[119]

Many European Jewish fathers during the nineteenth century chose not to circumcise their sons, including Theodor Herzl.[120][101] However, unlike many other forms of religious observance, it remained one of the last rituals Jewish communities could enforce. In most of Europe, both the government and the unlearned Jewish masses believed circumcision to be a rite akin to baptism, and the law allowed communities not to register uncircumcised children as Jewish. This legal maneuver spurred several debates addressing the advisibility of its use, since many parents later chose to convert to Christianity. In early 20th-century Russia, Chaim Soloveitchik advised his colleagues to reject this measure, stating that uncircumcised Jewish males are no less Jewish than Jews who violate other commandments.[97]

^Luke 2:21 (King James Version): "And when eight days were accomplished for the circumcising of the child, his name was called JESUS, which was so named of the angel before he was conceived in the womb."

^In the northern European calculation, which abstracts from the day from which the count begins, the interval was of seven days.

^Talmud Bavli Tractate Yebamoth 71b: Rabbah b. Isaac stated in the name of Rab: The commandment of uncovering the corona at circumcision was not given to Abraham; for it is said, At that time the Lord said unto Joshua: 'Make thee knives of flint etc.' But is it not possible [that this applied to] those who were not previously circumcised; for it is written, For all the people that came out were circumcised, but all the people that were born etc.? — If so, why the expression. 'Again!' Consequently it must apply to the uncovering of the corona.

^Rambam – Maimonides in his "book of laws" Laws of Milah Chapter 2, paragraph 2: "...and afterwards he sucks the circumcision until blood comes out from far places, in order not to come to danger, and anyone who does not suck, we remove him from practice."

^ abHartog, Kelly (February 18, 2005). "Death Spotlights Old Circumcision Rite". The Jewish Journal of Greater Los Angeles. Archived from the original on December 13, 2006. Retrieved 2006-11-22. Metzizah b’peh — loosely translated as oral suction — is the part of the circumcision ceremony where the mohel removes the blood from the baby’s member; these days the removal of the blood is usually done using a sterilized glass tube, instead of with the mouth, as the Talmud suggests.

^"Circumcision Protocol Regarding the Prevention of Neonatal Herpes Transmission". Department of Health, New York State. November 2006. Archived from the original on February 5, 2007. Retrieved 2006-11-23. The person performing metzizah b'peh must do the following: Wipe around the outside of the mouth thoroughly, including the labial folds at the corners, with a sterile alcohol wipe, and then discard in a safe place. Wash hands with soap and hot water for 2-6 minutes. Within 5 minutes before metzizah b'peh, rinse mouth thoroughly with a mouthwash containing greater than 25% alcohol (for example, Listerine) and hold the rinse in mouth for 30 seconds or more before discarding it.

^Novello, Antonia C. (May 8, 2006). "Dear Rabbi Letter". Department of Health, New York State. Archived from the original on February 18, 2007. Retrieved 2006-11-23. The meetings have been extremely helpful to me in understanding the importance of metzizah b'peh to the continuity of Jewish ritual practice, how the procedure is performed, and how we might allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health. I want to reiterate that the welfare of the children of your community is our common goal and that it is not our intent to prohibit metzizah b'peh after circumcision, rather our intent is to suggest measures that would reduce the risk of harm, if there is any, for future circumcisions where metzizah b'peh is the customary procedure and the possibility of an infected mohel may not be ruled out. I know that successful solutions can and will be based on our mutual trust and cooperation.

^Halperin, Mordechai (Winter 2006). Translated by Lavon, Yocheved. "Metzitzah B'peh Controversy: The View from Israel". Jewish Action. 67 (2): 25, 33–39. Archived from the original on March 6, 2012. Retrieved February 15, 2007. The mohel brings the baby’s organ into his mouth immediately after the excision of the foreskin and sucks blood from it vigorously. This action lowers the internal pressure in the tissues of the organ, in the blood vessels of the head of the organ and in the exposed ends of the arterioles that have just been cut. Thus, the difference between the pressure in the blood vessels in the base of the organ and the pressure in the blood vessels at its tip is increased. This requirement has deep religious significance as well as medical benefits....Immediately after incising or injuring an artery, the arterial walls contract and obstruct, or at least reduce, the flow of blood. Since the arterioles of the orlah, or the foreskin, branch off from the dorsal arteries (the arteries of the upper side of the organ), cutting away the foreskin can result in a temporary obstruction in these dorsal arteries. This temporary obstruction, caused by arterial muscle contraction, continues to develop into a more enduring blockage as the stationary blood begins to clot. The tragic result can be severe hypoxia (deprivation of the supply of blood and oxygen) of the glans penis.28 If the arterial obstruction becomes more permanent, gangrene follows; the baby may lose his glans, and it may even become a life-threatening situation. Such cases have been known to occur. Only by immediately clearing the blockage can one prevent such clotting from happening. Performing metzitzah immediately after circumcision lowers the internal pressure within the tissues and blood vessels of the glans, thus raising the pressure gradient between the blood vessels at the base of the organ and the blood vessels at its distal end—the glans as well as the excised arterioles of the foreskin, which branch off of the dorsal arteries. This increase in pressure gradient (by a factor of four to six!) can resolve an acute temporary blockage and restore blood flow to the glans, thus significantly reducing both the danger of immediate, acute hypoxia and the danger of developing a permanent obstruction by means of coagulation. How do we know when a temporary blockage has successfully been averted? When the “blood in the further reaches [i.e., the proximal dorsal artery] is extracted,” as Rambam has stated.

^The book was originally published in German, Die Ausübung der Mezizo, Frankfurt a.M. 1906; It was subsequently translated into Hebrew, reprinted in Jerusalem in 1966 under the title "Mitzvas Hametzitzah" and appended to the back of Dvar Sinai, a book written by the author's grandson, Sinai Adler.

^Philo of Alexandria; Colson, F.H. (trans.) (1937). Of the special laws, Book I (i and ii), in Works of Philo. Vol. VII. Loeb Classical Library: Harvard University Press. pp. 103–05. ISBN978-0674992504.

In the first half of the nineteenth century, various European governments considered regulating, if not banning, berit milah on the grounds that it posed potential medical dangers. In the 1840s, radical Jewish reformers in Frankfurt asserted that circumcision should no longer be compulsory. This controversy reached Russia in the 1880s. Russian Jewish physicians expressed concern over two central issues: the competence of those carrying out the procedure and the method used for metsitsah. Many Jewish physicians supported the idea of procedural and hygienic reforms in the practice, and they debated the question of physician supervision during the ceremony. Most significantly, many advocated carrying out metsitsah by pipette, not by mouth. In 1889, a committee on circumcision convened by the Russian Society for the Protection of Health, which included leading Jewish figures, recommended educating the Jewish public about the concerns connected with circumcision, in particular, the possible transmission of diseases such as tuberculosis and syphilis through the custom of metsitsah by mouth.
Veniamin Portugalov, who—alone among Russian Jewish physicians—called for the abolition of circumcision, set off these discussions. Portugalov not only denied all medical claims regarding the sanitary advantages of circumcision but disparaged the practice as barbaric, likening it to pagan ritual mutilation. Ritual circumcision, he claimed, stood as a self-imposed obstacle to the Jews’ attainment of true equality with the other peoples of Europe.